The Tavistock Primary Care Model in Hackney and Camden

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1 The Tavistock Primary Care Model in Hackney and Camden Medically Unexplained Symptoms and Medically Unexplored Stories Dr Julian Stern Tim Kent Carol Sibanda Ahmet Caglar MUS National Summit (Birmingham) May 10 th 2017

Dr Rhiannon England, City & Hackney GP - in 2009 What we wanted was a service which had very flexible referral criteria - based in surgeries, for GP referral only - and who could both see patients

2 Dr Rhiannon England, City & Hackney GP - in 2009 What we wanted was a service which had very flexible referral criteria - based in surgeries, for GP referral only - and who could both see patients and consult to GPs about patient management. (2009) We knew the service would have to be comprised of very experienced clinicians - as we also knew that the patients we were holding were often highly complex patients.

3 Structure of presentation 1. Origins of the service 2. Key principles including Outcome monitoring and health economics 3. Propagation of the model 4. Case material

4 City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS) * An innovative outreach service provided by the Tavistock and Portman NHS Foundation Trust-started in * Supports GPs to manage patients with complex mental health and other needs that result in frequent health service use. * Supports people with medically unexplained symptoms, personality disorders and chronic mental health problems. * Many have psychiatric co-morbidity and many also have poor physical health/ltc s.

5 The Development of the City & Hackney PCPCS Service specification: developed in collaboration with local stakeholders, including other service providers and GPs. GPs wanted less restrictive service design in terms of referral criteria: would lessen frustrating experience of patients being referred and then not accepted by services. GPs also knew patients who do not engage with mental health services: some who are not comfortable with their difficulties being viewed as having any psychological component. Delivering the service in GP surgeries could limit some of these concerns, enabling more integrated provision. (Carrington, Rock & Stern 2012).

6 The Development of the City & Hackney PCPCS - filling gaps Many well-established services in City and Hackney (Secondary Care Psychotherapy, IAPT and voluntary sector organisations) - but gaps in their ability to deal with some of the complex cases presenting to primary care. IAPT programme widened mental health provision for those people suffering with mild-moderate depressive and/or anxiety-related conditions. We reach out to patients in HoNos clusters 4-8 often more complex than those seen by IAPT, but not reaching threshold for secondary care mental health/psychiatry

7 Embedded in GP practices Service is embedded in local GP practices: supports GPs through consultation, coworking and training, and direct clinical service to patients. Experienced clinicians (mostly band 7 and upwards) who work from a range of models most appropriate to the presenting difficulties. Recently (Camden) in partnership with Mind in Camden (VSO)-delivering social prescribing (band 6 staff )

8 Our Dual Focus offer -to Patients & Staff Patients: Initial assessment (1-2, incl OM and basic data) Followed by Up to 16 sessions psychological therapy (Mean 8-9) Modalities include Brief dynamic, systemic, mentalisation, CBT, DIT Group Other innovations-gardening group, photography, social prescribing, GP practice/staff: Joint meetings with GP Case based discussion Training Consultancy

9 The Team TAP Tavi Camden

10 The Team- PCPCPS or Tavi Hackney

11 Based inside Primary Care alongside GPs

12 What we offer to patients Patients always seen in GP surgeries * Assessment Consultation (usually 2 sessions) identifying on-going care plan. * Extended consultation (typically offered over 4-6 sessions working on a specific issue identified in assessment). * Brief psychological treatment, one-to-one (6-16 week evidence-based psychological therapies,, dynamic interpersonal, mentalisation-based therapies, CAT, case management (psycho-social and systemic). Often acts as a trial of engagement, sometimes for the first time to consider a more emotional /psychological aetiology. * Group psychological treatment (brief structured psychotherapeutic or psychoeducational therapeutic groups; physical symptom groups; and mentalisation-based * Case management (face-to-face/telephone/service liaison). * Family work and couple therapy more expensive and limited but helpful.

13 What we offer our staff Individual supervision to help clinicians keep their patients engaged Weekly in depth supervision of their case material in small groups Weekly academic seminar and alternating team business meeting & case discussion seminar. Focus on quality and understanding. Opportunities for further professional development Requirement for high levels of measurable face to face patient activity, there is also a recognition of the need to attend to the wellbeing of staff and their ongoing development. High recruitment and retention, dedicated and passionate staff who collaborate

Our Dual Focus offer -to Patients & Staff Patients: Initial assessment (1-2, incl OM and basic data) Followed by Up to 16 sessions psychological therapy (Mean 8-9) Modalities include Brief dynamic,

14 Our Dual Focus offer -to Patients & Staff Patients: Initial assessment (1-2, incl OM and basic data) Followed by Up to 16 sessions psychological therapy (Mean 8-9) Modalities include Brief dynamic, systemic, mentalisation, DIT, Case Management. Group, family and couple Other innovations-gardening group, photography, social prescribing, GP practice/staff: Joint meetings with GP Case based discussion Training Consultancy

15 What we offer to GPs * Joint consultations with GPs and patients : 3 way consultation. Can shift a stuck situation, contain GP and offer a new lens to MUS / PPS and frequent attendance / over investigation due to shared anxiety * Professional consultation to GP and other primary care staff : 2 way consultation. * Complex Case based discussion with GPs and other practice staff. (Contemporary Balint in a Systems Psychodynamic style.) * Liaison with other services and agencies and Signposting to other appropriate services.

16 Our Staffing Structure-Camden TAP 0.6 wte

Horticultural groups, Care Planning service.

17 We haven t stood still Model & approach been built on flexibility, adaptability in the face of changing needs and context: work in A&E, Horticultural groups, Care Planning service. 2015: Won the bid - in partnership with MIND in Camden - to run the Camden TAP service (Team around the Practice).

18 % agreement PCPCS: Patient satisfaction PCPCS PEQ Data % 96% 84% 87% 84% 87% 80% 60% 40% 20% 0% PEQ Question

19 PCPCS: Patient satisfaction The Tavistock Primary Care service is open to people from all backgrounds, our ethos is more open than some traditional Secondary Care Psychotherapy services. Patient comments: * First time with counselling it was a positive experience. A lifeline. * I am happy with the service provided. This will help me with my day to day life and hopefully my future. I have learned a lot about myself, my thoughts and how to overcome any problems in future. Great friendly therapist always listening and helpful. * Having never had any psychotherapy before I find the service to be extremely useful. I wouldn't have been able to afford this privately on my income and am extremely grateful for the help/positive impact this has had on my well-being.

20 Patient interview

21 Layard and IAPT - the economic argument Layard s report and the IAPT project - built on a clear (flawed and simplistic) economic argument: (i) Depression and other mental health conditions are common: c people p.a. drawing incapacity benefit due to a mental health problem. (ii) Total annual cost of depression to the economy: 4% of GDP. (iii) 900,000 of people who draw incapacity benefit because of a mental health problem do not receive specialist mental health care: instead receive primary care, limited NHS counselling, private counselling where possible, or help from voluntary agencies. (iv) There are effective treatments, recommended by the National Institute for Health and Clinical Excellence (NICE).

22 Psychodynamic Therapy and the rise of Cognitive Behavioural Psychotherapy (CBT) Recently, CBT/other briefer therapies have come to the fore, epitomised in Improving Access to Psychological Therapies (IAPT) services (described below) - designed to lend themselves to scientific modes of assessing clinical effectiveness. Result: psychotherapy departments with long-term/psychodynamic focus - under substantial threat. Have been encouraged to embrace CBT, provide briefer forms of therapy, and become decentralised by moving into the community. Psychotherapy departments and other providers have closed (e.g. Henderson hospital). Others have often been radically changed: use outcome measures on a routine basis; tend to offer brief, sometimes manualised forms of therapy; and are almost always required to set a cap on the number of sessions offered.

23 Outcome monitoring, Health Economics and propagating the model * Capita (2011) * Centre for Mental Health (2014) * OPM (2016)

24 Ahmet Caglar Practitioner Psychotherapist Turkish Speaking Community Project

25 Community Project Horticultural Therapy / Therapeutic Horticulture Gardening the mind

26 Structure / How does it work? 1 year - weekly In a farm setting Talking + gardening + tea + cooking Less structured with talking and gardening 2 hours weekly

28 Some common issues Isolation loneliness: Most of the group members are experiencing isolation/loneliness. It is for the group I go out of the house most of the time I only share these things in the group. I don t know what to do when the group ends The effect of loneliness and isolation on mortality exceeds the impact of well-known risk factors e.g. obesity, and has a similar influence as cigarette smoking (Holt-Lunstad, 2010) Lonely individuals are more prone to depression (Cacioppo et al, 2006) (Green et al, 1992) Somatization & M.U.S Multiple physical conditions alongside emotional difficulties and lack of skills to manage them. Language barrier: Only a few patients in all groups can speak English. They rely on others in their interactions with health professionals. A few of them are illiterate.

29 Continued Trauma and multiple losses: Poverty, hardship back in Turkey (some political oppression), trafficked to the UK, asylum process. Difficulties in reflecting on possible (psychological) roots of their issues

30 Some concepts (suggestions) Accessing: (core issues) better understanding and experience of feelings as well as anxiety and defences. Finding ways to focus on the triangle of Feelings, Anxiety and Defences in a group situation. Presence : encouraging group members to be in contact with themselves (and others) in an embodied way also the awareness of what is going on in their experience (including the awareness of bodily sensations, thoughts and feelings) Contact: is the quality of presence in interpersonal interactions. It also includes among others, appreciation, warmth and of human interaction. Here and now: Encouraging interactive work through here/this/now rather than there/that/then. It does not easily happen in early days and difficult in shorter groups.

31 ..culture and ethos of groups Introducing change: via simple action planning, problem solving and feedback sessions. Sometimes may require long term and intensive work. Joining some of the activities e.g. action planning. Using gardening and nature in a symbolic way: seed, potential, sowing, germination, growth, weeds, fruiting, seasons, death etc Being realistic: rather than pessimistic or optimistic.

32 Two different groups with similar aims 1 year - weekly In a farm setting Talking + gardening + tea + cooking Less structured with talking and gardening 2 hours weekly

Clinical Case Study Ms Carol Sibanda- PCPCPS Co-ordinator & Specialist Nurse Psychotherapist. GP and patient serious concerns Long and complex history.

33 Clinical Case Study Ms Carol Sibanda- PCPCPS Co-ordinator & Specialist Nurse Psychotherapist. GP and patient serious concerns Long and complex history. Physical and medical : some explained some not Need for very careful listening and digestion Skill and experience very important in treatment Cultural factors important Communication via skin as well as voice.

34 Tim Kent Tavistock Primary Care Service Lead Consultant Psychotherapist & Social Worker

35 Community Photography Group

36 Care for the Carers. Curiosity alongside Cure. Balint for the 21 st century? Demand for GP supervision groups up. Feedback consistently positive and hungry Recruitment, retention and sustenance need emotional as well as physical resources. Team as family issues come up- thinking space. GP and staff all have valence & vulnerability for particular types of patient and psychopathology, can he part of helping, also potential risk. Admin and reception together or apart from GPs?

37 GP Feedback March 2017 PCPCPS consultation feedback. We, the staff at Pressure Cooker Road Practice, often feel very overwhelmed by our work which involves working with patients with very complex psychological symptoms. The Group-based Consultation work provided by the Tavistock each month fulfils an unmet need with crucial learning and feedback in an area that we are not adequately trained. It is an opportunity for us to share our experiences with all our colleagues: clinicians, reception, administrative staff.

38 Conferences Dr Alexis Brook memorial lecture. Hoxton surgery GP & Cons Psychiatrist

Thinking space alongside creative activity. Square foot system of gardening can feel more manageable. Time to talk and do Memories of mother and child.

39 Thinking space alongside creative activity. Square foot system of gardening can feel more manageable. Time to talk and do Memories of mother and child.. Attachment security promoted through proximity and shared learning. Back to my roots? Making and eating satisfaction + pleasure. Heat and toxicity of trauma moderated.

Centre for Mental Health report: impact March 2016, Nick Clegg MP: Last week I visited a team of clinicians at the Tavistock and Portman Mental Health

40 Centre for Mental Health report: impact March 2016, Nick Clegg MP: Last week I visited a team of clinicians at the Tavistock and Portman Mental Health Trust at St Leonard s Hospital in Hackney. It does something that makes obvious sense: it places mental health specialists in GP surgeries around the borough.

41 What have we struggled with? Managing demand waiting times. Patient choice most MH patients don t know they can choose. Space in Primary Care Demands made by NHS England of local CCGs access targets + STP more for less, less for more, invest to save? Short term political investment e.g. Better Care Fund. Contract security staff security and state of mind.

42 Centre for Mental Health report: Geraldine Strathdee Included a foreword by Dr Geraldine Strathdee, National Clinical Director for Mental Health, NHS England. I hope that this report will inspire family doctors and clinical commissioning groups across the country. By combining local innovation with learning from the experiences of others, the NHS can offer better care despite the tough financial climate. This is a challenge we cannot, and must not, ignore.

43 Centre for Mental Health report: impact King s Fund report : A multidisciplinary team of mental health professionals attend GP practices to help GPs manage patients with complex needs, typically characterised by a mix of physical symptoms, long-term mental health problems and challenging social circumstances. One of the service s successes is the co-location of the GP and the psychotherapists, which is seen to deliver benefits for both the medical staff and patients. GPs were reported to appreciate the assistance they receive with patients they see regularly, and patients appreciate not having to be referred to another service.

44 Key References Carrington A, Rock B and Stern J (2102) : Psychoanalytic thinking in primary care: The Tavistock Psychotherapy Consultation model. Psychoanalytic Psychotherapy, vol. 26, no. 2, pp Hard E, Rock B and Stern J (2015) Paradigms, Politics and Pragmatics: Psychotherapy in Primary Care in City and Hackney - a new model for the NHS. Part 2. Psychoanalytic Psychotherapy 29, 2 : Parsonage, M., Hard, E. & Rock, B. (2014) Managing patients with complex needs: Evaluation of the City and Hackney Primary Care Psychotherapy Consultation Service. Centre for Mental Health, UK Stern J, Hard E and Rock B (2015) Paradigms, Politics and Pragmatics: Psychotherapy in Primary Care in City and Hackney - a new model for the NHS. Part 1. Psychoanalytic Psychotherapy 29, 2 : Stern J, Yon K, Kent T (2016) Taking mental health a step beyond primary care. Health Services Journal (HSJ) 10 June 2016

45 Thank you for coming and taking part. Dr Julian Stern Director Adult and Forensic Services, Consultant Psychiatrist in Psychotherapy Mr Tim Kent, Primary Care Service Lead, Consultant Primary Care Psychotherapist and Social Worker

The Tavistock Primary Care Model in Hackney and Camden

The Tavistock Primary Care Model in Hackney and Camden The King s Fund 2017 Primary Care Mental Health Medically Unexplored Stories Tim Kent Primary care Service Lead, Consultant Primary Care Psychotherapist